INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 9, 2025 through September 10, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Summit BHC Westfield, LLC dba Mountain Laurel Recovery Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on the review of personnel records, the project failed to document a written initial individual training plan for each employee within thirty days, appropriate to that employee's skill level with input from both the employee and the supervisor in two out of ten records reviewed. Employee #2 was hired on April 7, 2025 as a clinical supervisor and was current in that position. The initial individual training plan was to be documented by May 7, 2025; however, it was not documented in the personnel record until September 5, 2025.Employee #9 was hired on August 5, 2025 as a counselor and was current in that position. The initial individual training plan was to be documented by April 11, 2025; however, it was not documented in the personnel record until September 5, 2025.This is a repeat citation from the August 28, 2024 annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/20/25 the Director of Quality Improvement & Risk Management will train the Human Resources Manager on DDAP regulation 704.11(b)(1) Individual Training Plan to ensure thorough comprehension of the requirements and adherence to compliance standards. An attestation will be signed and placed in their designated HR file.
The Human Resources Manager revised the training plan process to ensure that supervisors complete individual training plans with employees within 30 days of hire. Each plan will be appropriate to the employee's skill level and developed collaboratively between the staff and their supervisor.
Training plans for newly hired employees will be integrated into the onboarding process and subject to ongoing monitoring by the Human Resources Manager. In addition, the process will be implemented on an annual basis for all employees.
For monitoring and compliance, the Human Resources Manager will audit 100% of new employee files, with a goal of 100% compliance to ensure that individual training plans are completed within 30 days of hire, are appropriate to each employee's skill level, and have input from both the employee and supervisor. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board. Due to the repeated findings from the state, this audit shall remain in effect until such time as the Governing Board authorizes its reduction or discontinuation.
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, the facility failed to ensure that one of ten employees received a minimum of four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.Employee # 10 was hired as a counselor on August 13, 2024, and was due to have the communicable disease trainings no later than August 13, 2025. There was no documentation that the employee received four training hours of TB/STD at the time of the inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/27/25 the Director of Quality Improvement & Risk Management will train the Infection Control Nurse on DDAP regulation 704.11(c)(1) Mandatory Communicable Disease Training to ensure thorough comprehension of the requirements and adherence to compliance standards. An attestation will be signed and placed in their designated HR file.
By 10/20/25the identified counselor will have completed the required 4-hour TB/STD training using a department-approved curriculum.
The Infection Control Nurse is responsible for ensuring that staff complete TB/STD and other department-approved curriculum by the timelines outlined in the regulation. The Infection Control Nurse will monitor course completion through tracking and auditing and will collaborate with the Human Resources Manager to ensure that training is assigned and completed by employees within the required timeframes.
For monitoring and compliance, the Infection Control Nurse will audit 100% of new employee files, with a goal of 100% compliance, to verify timely completion of required TB/STD training courses. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board. Due to the timeframes set forth in the regulation for course completion, the audit shall remain in effect until such time as the Governing Board authorizes its reduction or discontinuation.
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in three of three applicable records reviewed.Client #1 was admitted to the inpatient non-hospital detox level of care on November 26, 2024 and was discharged Against Staff Advice (ASA) on November 30, 2024. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.Client #3 was admitted to the inpatient non-hospital detox level of care on February 19, 2025 and was discharged Against Staff Advice (ASA) on February 23, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.Client #12 was admitted to the inpatient non-hospital residential level of care on January 17, 2025 and was discharged Against Staff Advice (ASA) on February 3, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.This is a repeat citation from the October 5, 2022, October12, 2023 and the August 28, 2024 annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/20/25 the Director of Quality Improvement & Risk Management will train the Clinical Supervisor on DDAP regulation 709.24(a)(3) Treatment/rehabilitation Management to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/2025, the Clinical Supervisor will provide training to the clinical services staff on Policy # PS-007, titled "Transition Discharge," to ensure understanding and adherence to the process for contacting the emergency contact of patients who leave ASA within twelve hours of discharge and documenting the attempt or contact in the medical record.
For monitoring and compliance, the Director of Clinical Services will audit 15 closed medical records each month, with a goal of 100% compliance to review compliance with contacting the patient's emergency contact within twelve hours after an ASA discharge. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board. Due to the repeated findings from the state, this audit shall remain in effect until such time as the Governing Board authorizes its reduction or discontinuation.
|
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.Client #4 was admitted on March 6, 2025 and was discharged on March 8, 2025. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred. This is a repeat citation from the August 28, 2024 annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/20/25, the Director of Quality Improvement & Risk Management will train the Director of Nursing and Director of Admission on DDAP regulation 709.28(c) Confidentiality to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25 the Director of Nursing and Director of Admissions will have provided training to their respective employees on Policy # RS-007, titled "Release of Protected Health Information" related to Release of Information (ROI's) and obtaining informed and voluntary consent from patients for the disclosure of information to funding sources.
For monitoring and compliance, the Director of Admissions will audit 15 Source of Funding ROI's each month, with a goal of 100% compliance, for 90 consecutive days, to verify compliance for obtaining informed and voluntary consent from patients for the disclosure of information to funding sources. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until the compliance goal is met.
|
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of fourteen records reviewed.Client #5 was admitted on May 14, 2025 and was discharged on May 21, 2025. A release of information form, signed by the client on May 15, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/20/25, the Director of Quality Improvement & Risk Management will train the Director of Nursing and Director of Admission on DDAP regulation 709.28(c) Confidentiality to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25 the Director of Nursing and Director of Admissions will have provided training to their respective employees on Policy # RS-007, titled "Release of Protected Health Information" related to Release of Information (ROI's) and obtaining informed and voluntary consent from patients for the disclosure of information to funding sources.
For monitoring and compliance, the Director of Admissions will audit 15 Source of Funding ROI's each month, with a goal of 100% compliance, for 90 consecutive days, to verify compliance for obtaining informed and voluntary consent from patients for the disclosure of information to funding sources. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until the compliance goal is met.
|
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of fourteen client records reviewed.Client #6 was admitted on June 1, 2025 and discharged on June 8, 2025. Two release of information forms for the county court and emergency contact, signed by the client on June 4, 2025, did not specify the purpose of disclosure.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 10/20/25, the Director of Quality Improvement & Risk Management will train the Director of Nursing and Director of Admission on DDAP regulation 709.28(c) Confidentiality to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25 the Director of Nursing and Director of Admissions will have provided training to their respective employees on Policy # RS-007, titled "Release of Protected Health Information" related to Release of Information (ROI's) and obtaining informed and voluntary consent from patients for the disclosure of information to funding sources.
For monitoring and compliance, the Director of Admissions will audit 15 Source of Funding ROI's each month, with a goal of 100% compliance, for 90 consecutive days, to verify compliance for obtaining informed and voluntary consent from patients for the disclosure of information to funding sources. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until the compliance goal is met.
|
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in one of fourteen client records reviewed. Client #8 was admitted on August 15, 2025, and was active at the time of the inspection. A release of information for the funding source was documented in the record on August 15, 2025; however, the form was not signed and dated by the client. This is a repeat citation from the August 28, 2024 annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/20/25, the Director of Quality Improvement & Risk Management will train the Director of Nursing and Director of Admission on DDAP regulation 709.28(c) Confidentiality to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25 the Director of Nursing and Director of Admissions will have provided training to their respective employees on Policy # RS-007, titled "Release of Protected Health Information" related to Release of Information (ROI's) and obtaining informed and voluntary consent from patients for the disclosure of information to funding sources.
For monitoring and compliance, the Director of Admissions will audit 15 Source of Funding ROI's each month, with a goal of 100% compliance, for 90 consecutive days, to verify compliance for obtaining informed and voluntary consent from patients for the disclosure of information to funding sources. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until the compliance goal is met.
|
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on the review of client records, the project failed to offer a copy of release of information forms in one of fourteen client records reviewed.Client #8 was admitted on August 15, 2025, and was active at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for another provider, that signed and dated by the client on August 26, 2025.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/20/25, the Director of Quality Improvement & Risk Management will train the Director of Nursing and Director of Admission on DDAP regulation 709.28(c) Confidentiality to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25 the Director of Nursing and Director of Admissions will have provided training to their respective employees on Policy # RS-007, titled "Release of Protected Health Information" related to Release of Information (ROI's) and obtaining informed and voluntary consent from patients for the disclosure of information to funding sources.
For monitoring and compliance, the Director of Admissions will audit 15 Source of Funding ROI's each month, with a goal of 100% compliance, for 90 consecutive days, to verify compliance for obtaining informed and voluntary consent from patients for the disclosure of information to funding sources. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until the compliance goal is met.
|
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two applicable client record reviewed.Client #4 was admitted on March 6, 2025 and was involuntarily discharged on March 8, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.Client #11 was admitted on November 11, 2024 and was involuntarily discharged on November 24, 2024. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/17/25 the Director of Quality Improvement & Risk Management will train the Clinical Supervisor on DDAP regulation 709.33(a) Notification of Termination to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
It is the responsibility of the Clinical Supervisor or in their absence, their assigned designee to notify the patient in writing of any decision concerning the involuntary termination of treatment.
On 9/24/25, the facility revised the "Notification of Discharge Letter" to include a patient signature line and a witness signature line to provide documentation that the letter was offered to the individual. In addition, a new scanning process has been implemented by clinical services to ensure compliance with scanning such letters into the medical record for compliance. Training on the new processes was completed with clinical services staff by 10/20/25.
For monitoring and compliance, the Clinical Supervisor will audit 100% of Administrative Involuntary Discharges each month, with a goal of 100% compliance, for 60 consecutive days, to ensure the "Notification of Discharge Letter" is completed and scanned into the medical record. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until the compliance goal is met.
|
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving a physical or sexual assault by staff or a client.On July 12, 2025, a client reported to a staff member that there was a physical altercation between multiple clients at the facility. This incident was confirmed by other clients at the facility. The staff member reported the incident to the clinical director on July 13, 2025. A written unusual incident report was not filed with the Department.On July 12, 2025, a client reported being sexually assaulted on July 11, 2025, by another client. A written unusual incident report was not filed with the Department.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/17/25, the facility's Corporate Director of Quality and Patient Safety will provide the facility's Director of Quality Improvement and Risk Management (DQIRM) and Chief Executive Officer (CEO) education based on Pa. Code § 709.34 (c) (1) Reporting of Unusual Incidents and the DQIRM's responsibility to report unusual incidents to the Department within 3 business days following an incident of physical or sexual assault by staff or a client. It is the responsibility of the CEO shall hold the DQIRM accountable for self-reporting to the department when incidents occur that meet the required reporting guidelines and will monitor during morning FLASH meetings.
The DQIRM will review 100% of incident reports to monitor events that meet departmental reporting requirements and initiate investigations as needed.
The DQIRM will notify the CEO and Corporate Director of Quality and Patient Safety if an incident meets self-reporting requirements.
The DQIRM is responsible for tracking and trending 100% of incidents and report data monthly to the Committee of the Whole (COW) and quarterly to the Governing Board.
|
709.63(a)(7) LICENSURE Discharge summary
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(7) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary, in three of seven records reviewed. Client #1 was admitted on November 26, 2024 and was discharged on November 30, 2024. The record did not contain a discharge summary.Client #6 was admitted on June 1, 2025 and discharged on June 8, 2025. The record did not contain a discharge summary.Client #7 was admitted on June 12, 2025 and was discharged on June 19, 2025. The record did not contain a discharge summary.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/17/25, the Chief Executive Officer (CEO) will review regulation Pa. Code § 709.63 (a) (7) Discharge Summary with the Medical Director to ensure understanding and compliance that each patient be provided with a completed discharge summary to include a recapitulation of the patient's stay. An attestation will be signed and placed in the provider's file.
By 10/20/25, the Clinical Supervisor will provide training to clinical staff on Pa. Code § 709.63(a)(7) Discharge Summary to ensure understanding and compliance with the requirement that each patient is provided with a discharge summary documenting their participation in treatment. An attestation will be signed and placed in the Clinical Supervisors file.
By 10/27/25 the Medical Director will provide training to medical staff on Pa. Code § 709.63(a)(7) Discharge Summary to ensure understanding and compliance with the requirement that each patient is provided with a discharge summary documenting their participation in treatment. An attestation will be signed and placed in the provider's file.
For monitoring and compliance, the Quality Review Coordinator will audit 10 closed records each month, with a goal of 100% compliance, for 90 consecutive days, to ensure discharge summaries are completed in the medical record. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until compliance goals are met.
|
709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information, in two of six applicable records reviewed. The facility policy indicates follow ups will not be completed on involuntary discharges. Client #1 was admitted on November 26, 2024 and was discharged on November 30, 2024. The record did not contain follow-up information.Client #3 was admitted on February 19, 2025 and was discharged on February 23, 2025. The record did not contain follow-up information.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 10/27/25 the Director of Quality Improvement & Risk Management will train the Clinical Supervisor on DDAP regulation 709.63(a) (8) Follow-up Information to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25, the DQIRM will revise Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to specify the types of patient discharges that will receive follow-up calls, to include involuntary discharged patients.
By 10/24/25, the alumni Coordinator will receive education on the revised Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to ensure understanding of the updated policy and procedure.
For monitoring and compliance, the Director of Business Development will audit 10 closed records each month, with a goal of 100% compliance, for 60 consecutive days to ensure follow-up calls are completed as outlined in the facility's policy. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until compliance goals are met.
|
709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on the review of the facility ' s policy and procedure manual, the facility failed to develop a follow-up policy to include following up on all clients that had been discharged from the facility. The facility policy indicates that follow-ups are not completed on involuntary discharges. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 10/27/25 the Director of Quality Improvement & Risk Management will train the Clinical Supervisor on DDAP regulation 709.63(a) (8) Follow-up Information to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25, the DQIRM will revise Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to specify the types of patient discharges that will receive follow-up calls, to include involuntary discharged patients.
By 10/24/25, the alumni Coordinator will receive education on the revised Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to ensure understanding of the updated policy and procedure.
For monitoring and compliance, the Director of Business Development will audit 10 closed records each month, with a goal of 100% compliance, for 60 consecutive days to ensure follow-up calls are completed as outlined in the facility's policy. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until compliance goals are met.
|
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of the seven applicable records reviewed. Client #8 was admitted on August 15, 2025, and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 17, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #9 was admitted on August 18, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 20, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #10 was admitted on August 19, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 21, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #11 was admitted on November 11, 2024 and was discharged on November 24, 2024. The individual treatment and rehabilitation plan was completed on November 21, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #12 was admitted on January 17. 2025 and was discharged on February 3, 2025. The individual treatment and rehabilitation plan was completed on January 21, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #13 was admitted on March 4, 2025 and was discharged on April 3, 2025. The individual treatment and rehabilitation plan was completed on March 6, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #14 was admitted on June 15, 2025 and was discharged on July 24, 2025. The individual treatment and rehabilitation plan was completed on June 16, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.This is a repeat citation from the August 28, 2024 annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 10/27/25 the Director of Quality Improvement & Risk Management will train the Clinical Supervisor on DDAP regulation 709.52(a) (2) Tx Type & Frequency to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/17/2025, the Clinical Supervisor will educate clinical staff on Pa. Code § 709.52(a)(2) Tx Type & Frequency to ensure compliance with documentation of type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
For monitoring and compliance, the Clinical Supervisor will audit 15 treatment plans each month, with a goal of 100% compliance, for 90 consecutive days to ensure type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan is documented. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until compliance goals are met.
|
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary, in two of four applicable records reviewed. Client #11 was admitted on November 11, 2024 and was discharged on November 24, 2024. The record did not contain a discharge summary.Client #12 was admitted on January 17. 2025 and was discharged on February 3, 2025. The record did not contain a discharge summary.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 10/17/25, the Chief Executive Officer (CEO) will review regulation Pa. Code § 709.63 (a) (7) Discharge Summary with the Medical Director to ensure understanding and compliance that each patient be provided with a completed discharge summary to include a recapitulation of the patient's stay. An attestation will be signed and placed in the provider's file.
By 10/20/25, the Clinical Supervisor will provide training to clinical staff on Pa. Code § 709.63(a)(7) Discharge Summary to ensure understanding and compliance with the requirement that each patient is provided with a discharge summary documenting their participation in treatment. An attestation will be signed and placed in the Clinical Supervisors file.
By 10/27/25 the Medical Director will provide training to medical staff on Pa. Code § 709.63(a)(7) Discharge Summary to ensure understanding and compliance with the requirement that each patient is provided with a discharge summary documenting their participation in treatment. An attestation will be signed and placed in the provider's file.
For monitoring and compliance, the Quality Review Coordinator will audit 10 closed records each month, with a goal of 100% compliance, for 90 consecutive days, to ensure discharge summaries are completed in the medical record. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until compliance goals are met.
|
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
|
Observations
Based on the review of the facility ' s policy and procedure manual, the facility failed to develop a follow-up policy to include following up on all clients that had been discharged from the facility. The facility policy indicates that follow-ups are not completed on involuntary discharges. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 10/27/25 the Director of Quality Improvement & Risk Management will train the Clinical Supervisor on DDAP regulation 709.63(a) (8) Follow-up Information to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25, the DQIRM will revise Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to specify the types of patient discharges that will receive follow-up calls, to include involuntary discharged patients.
By 10/24/25, the alumni Coordinator will receive education on the revised Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to ensure understanding of the updated policy and procedure.
For monitoring and compliance, the Director of Business Development will audit 10 closed records each month, with a goal of 100% compliance, for 60 consecutive days to ensure follow-up calls are completed as outlined in the facility's policy. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until compliance goals are met.
|
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on the review of the facility ' s policy and procedure manual, the facility failed to develop a follow-up policy to include following up on all clients that had been discharged from the facility. The facility policy indicates that follow-ups are not completed on involuntary discharges. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 10/27/25 the Director of Quality Improvement & Risk Management will train the Clinical Supervisor on DDAP regulation 709.63(a) (8) Follow-up Information to ensure thorough comprehension of the requirements and adherence to compliance standards. Attestation will be signed and placed in their designated HR file.
By 10/20/25, the DQIRM will revise Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to specify the types of patient discharges that will receive follow-up calls, to include involuntary discharged patients.
By 10/24/25, the alumni Coordinator will receive education on the revised Policies #PS-020 & PS-021 titled "Post Discharge Follow Up Residential and Post Discharge Follow Up Detox to ensure understanding of the updated policy and procedure.
For monitoring and compliance, the Director of Business Development will audit 10 closed records each month, with a goal of 100% compliance, for 60 consecutive days to ensure follow-up calls are completed as outlined in the facility's policy. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board until compliance goals are met.
|
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with a plan of correction that was approved by the Department. A plan of correction for follow policy related to against staff advice (ASA) discharges by calling the emergency contact within twelve hours of an ASA discharge was submitted and approved by the Department for the October 5, 2022, October 12, 2023, and August 28, 2024, annual licensing inspections. Following policy related to ASA discharges was again found to be a deficiency in the June 27, 2025, annual licensing inspection.A plan of correction for obtaining an informed and voluntary consent from the client prior to the disclosure of information in the client record was submitted and approved by the Department for the August 28, 2024, annual licensing inspection. Obtaining an informed and voluntary consent from the client prior to the disclosure of information in the client record was again found to be a deficiency in the June 27, 2025, annual licensing inspection.A plan of correction for obtaining an informed and voluntary consent from the client that included a dated client signature was submitted and approved by the Department for the August 28, 2024, annual licensing inspection. Obtaining an informed and voluntary consent from the client that included a dated client signature was again found to be a deficiency in the June 27, 2025, annual licensing inspection.A plan of correction for documenting the type and frequency of treatment and rehabilitation services on an individual ' s treatment and rehabilitation plan was submitted and approved by the Department for the August 28, 2024, annual licensing inspection. Documenting the type and frequency of treatment and rehabilitation services on an individual ' s treatment and rehabilitation plan was again found to be a deficiency in the June 27, 2025, annual licensing inspection.A plan of correction for documenting a written individual training plan for each employee was submitted and approved by the Department for the August 28, 2024, annual licensing inspection. Documenting a written individual training plan for each employee was again found to be a deficiency in the June 27, 2025, annual licensing inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The leadership and staff of Mount Laurel are fully committed to achieving and maintaining full compliance with all applicable state regulations governing our operations. We recognize the importance of adhering to these standards to ensure the safety, quality of care, and well-being of the patients we serve.
Please note, that the leadership team have undertaken a comprehensive review of our policies, procedures, and practices, and are actively implementing corrective actions to address any identified gaps. This includes:
- New leadership and accountability
- New Corporate Leadership and Advisement
- Updating and reinforcing staff training programs.
- Enhancing documentation and auditing processes.
- Implementing systems to ensure timely reporting and follow-up.
- Monitoring and evaluating compliance through regular internal audits and oversight.
- Enhanced Governing Board oversight.
Our facility is committed to transparency, accountability, and continuous improvement. We will work diligently to ensure that all regulatory requirements are consistently met and sustained.
|